Deck 2 Module 13 Mobility Flashcards
During the assessment of a client, the nurse finds that the client’s lower extremities are both warm, sensation is intact, and motion is unrestricted. What does this finding suggest to the nurse?
A) Skeletal muscle attached to bones via tendons is performing correctly.
B) Smooth muscle attached to bones via ligaments will require further assessment.
C) Cartilage connecting bones has a good blood supply.
D) Muscle connecting the axial skeleton is compromised.
A) Skeletal muscle attached to bones via tendons is performing correctly.
Rationale: Contraction of skeletal muscle attached to bones via tendons creates movement. Smooth muscle is not attached to bones. Cartilage is not vascular. The axial skeleton is not part of the lower extremities.
The nurse is caring for a client who is at risk for developing an alteration in mobility. Which modifiable risk factor will the nurse focus in order to decrease the risk this client’s risk?
A) Age
B) Gender
C) Weight
D) Ethnicity
C) Weight
Rationale: Weight is a modifiable risk factor that the nurse can focus on when planning care for a client who is experiencing an alteration in mobility. The nurse can teach the client to eat a more balanced diet and increase physical activity. Age, gender, and ethnicity are non-modifiable risk factors.
The mother of a preadolescent client is concerned because the client often reports non-specific “bone pain.” Which response by the nurse is appropriate?
A) “Bone pain in children is caused from the pulling of muscles when bones grow quickly.”
B) “The child needs to rest more when the bones hurt.”
C) “Non-specific bone pain means there is a disease process somewhere else in the body.”
D) “It is a symptom that needs further investigation and will be reported to the physician.”
A) “Bone pain in children is caused from the pulling of muscles when bones grow quickly.”
Rationale: The rapid bone growth of childhood may lead to “growing pains” as muscles are pulled when bones grow quickly. Non-specific bone pain in a child is not a symptom that needs further investigation and does not need to be reported to the physician. Bone pain does not mean that the child needs to rest more. Non-specific bone pain does not mean that there is a disease process somewhere else in the body.
The school nurse is conducting a screening on back safety for school-age clients who are in the 6th grade. The nurse brings a scale and weighs all the children and their backpacks behind a screen for privacy. One client weighs 40 kg and the backpack weighs 8 kg. Which intervention is appropriate for this client?
A) Tell the student that the backpack is not too heavy for his weight.
B) Budget for rolling backpacks for all the students.
C) Explain the risks of heavy backs and alternatives to the student’s parents.
D) Tell the student that to take some items out of the backpack.
C) Explain the risks of heavy backs and alternatives to the student’s parents.
Rationale: If possible, backpacks should weigh no more than 10% of the child’s body weight. This child’s backpack weighs 20% of his body weight, increasing his risks for alterations in the alignment of the spinal column as well as significant pain. The best intervention would be to explain the risk of heavy backpacks and the alternatives to the student’s parents. Although rolling backpacks are a viable alternative to decrease the risk of back injury, it may not be feasible to budget these for all the students. Telling the student he must take items out of the backpack has a low probability for success.
A client with Parkinson disease (PD) states to the nurse, “It is 1950 and I am late for work.” What action should the nurse take at this time?
A) Orient the client, provide a calendar, and place a clock in the room.
B) Ask the client what life is like in 1950.
C) Medicate for confusion.
D) Apply restraints so the client will not attempt to get out of bed to go to work.
A) Orient the client, provide a calendar, and place a clock in the room.
Rationale: Clients with PD may demonstrate confusion and disorientation. This is what the client is demonstrating. The nurse should orient the client, provide a calendar, and place a clock in the room to assist with ongoing orientation. The nurse should not medicate the client for confusion or apply restraints. The nurse should not feed into the confusion by asking what life is like in 1950.
A client admitted 3 days prior with an injury to the thoracic area of the spinal cord tells the nurse, “I’m getting worse. It’s harder to breathe.” Based on this data, which does the nurse suspect?
A) The client has atelectasis.
B) The extent of injury cannot yet be determined.
C) The client is improving.
D) The client is developing pneumonia.
B) The extent of injury cannot yet be determined.
Rationale: With a spinal cord injury, there is an area of ischemia and edema. Because edema extends from the level of injury for two cord segments above and below the affected level, the extent of injury cannot be determined for up to 1 week. The client’s complaint of it being harder to breathe could be evidence that extent of injury is becoming more obvious but will not be totally determined for a few more days. The client’s complaint of it being harder to breathe may or may not indicate pneumonia or atelectasis. The complaint is not evidence that the client is improving.
